Purpose:
The purpose of this bulletin is to provide education to the provider community regarding billing errors when billing codes J9055, J2405, J9310, and J9265.  The Healthcare Common Procedure Coding System (HCPCS) Level II National Codes are used to identify and report medications.  Medications should be billed using the correct HCPCS for the medication that is being administered and the correct number of units should be entered for the dose that is being administered. 

Background:
Highmark Medicare Services would like to remind all providers to be attentive to the description of the HCPCS code when billing medications.  The definition of the HCPCS code specifies the lowest common denominator of the amount of the dosage.  Providers should utilize the units field as a multiplier to arrive at the dosage amount. For example, J9055 is described as an Injection of Cetuximab, 10 mg. For a total dosage of 80mg, the provider should show 8 in the units field by using the following calculation: 80mg/10mg equals 8 units.  J2405 is described as an injection of Ondansetron HCL, per 1 mg.  For a total dosage of 5 mg, the provider should show 5 in the units field (5mg/1mg equals 5 units).  J9310 is described as Rituximab per 100 mg.  For a total dosage of 1,000 mg, the provider should show 10 in the units field (1,000mg/100mg equals 10 units).  J9265 is described as Paclitaxel per 30 mg.  For a total dosage of 600 mg, the provider should show 20 in the units field (600mg/30mg equals 20 units). 

It is expected that the medical record will contain the name of the drug, dosage, route of administration, time and date given. When a portion of the drug is discarded, the medical record must clearly document the amount administered and the amount wasted. 

Coverage of discarded drugs applies only to single use vials. Multi-use vials are not subject to payment for discarded amounts of drug.  An itemized bill should be submitted with the claim to verify how the drug was supplied.  The claim should also include the amount of drug administered and the amount of drug "wasted" by referencing the appropriate JW modifier which signifies the “Drug Amount Discarded/Not Administered to Any Patient” as directed in the CMS Manual 100-04, Chapter 17, “Drugs and Biologicals” Subsections 40 and 100.2.9 located at http://www.cms.hhs.gov/manuals/downloads/clm104c17.pdf.

Provider Action:
Documentation in the medical record must contain a history and physical pertinent to the indications and medical necessity for administering the drug.  Ensure the number of units is accurate when billing medications to Medicare and supported in the medical record documentation. 

References:

1. Highmark Medicare Services FAQs 
   
   
2. The Medicare Claims Processing Manual, Chapter 17, “Drugs and Biologicals”
   
   
3. Highmark Medicare Services Website Medical Policy Section

Assistance:

If you have any questions regarding this bulletin, please contact the appropriate Customer Contact Center at:

Maryland/DC Providers: 1-866-488-0545
Pennsylvania Providers: 1-800-560-6170

This bulletin should be shared with all health care practitioners and managerial members of the provider/supplier staff.  Additional copies may be downloaded from our website.